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Open Access Publications from the University of California

Volume 22, Issue 5, 2021

Endemic Infections

Use of Telemedicine to Expedite and Expand Care During COVID-19

Introduction: The novel coronavirus disease 2019 (COVID-19) created challenges with access to care including increased burden on healthcare systems and potential exposure risks for vulnerable patients. To address these needs, Rush University Medical Center created a virtual, urgent care program specifically designed to address these challenges during the COVID-19 pandemic.

Methods: This was a retrospective study analyzing adult patients with COVID-19-related telemedicine visits performed between March 1–June 30, 2020. COVID-19-related telemedicine visits refer to those who used the “Concern for Coronavirus” module. We assessed the total number of telemedicine visits using this module, percentage with a subsequent emergency department (ED) visit within seven days, and outcomes (ie, hospitalization status, intubation, and death) of patients who presented to the ED for evaluation. Data are presented using descriptive statistics.

Results: A total of 2,974 adult patients accessed the program via the COVID-19 module over the four-month period. Of those, 142 patients (4.8%) had an ED visit within seven days. Only 14 patients (0.5%) required admission. One patient was intubated, and there were no deaths among the telemedicine population.

Conclusion: The data suggests that telemedicine may be a safe and effective way to screen and treat patients with possible COVID-19, while reducing potential burdens on EDs.

  • 1 supplemental ZIP

Patient Perceptions of Drive-through Medical Treatment Facilities During the COVID-19 Pandemic

Introduction: The cumulative burden of coronavirus disease 2019 (COVID-19) on the United States’ healthcare system is substantial. To help mitigate this burden, novel solutions including telehealth and dedicated screening facilities have been used. However, there is limited data on the efficacy of such models and none assessing patient comfort levels with these changes in healthcare delivery. The aim of our study was to evaluate patients’ perceptions of a drive-through medical treatment system in the setting of the COVID-19 pandemic. 

Method: Patients presenting to a drive-through COVID-19 medical treatment facility were surveyed about their experience following their visit. An anonymous questionnaire consisting of five questions, using a five-point Likert scale was distributed via electronic tablet. 

Results: We obtained 827 responses over two months. Three quarters of respondents believed care received was similar to that in a traditional emergency department (ED). Overall positive impression of the drive-through was 86.6%, and 95% believed that it was more convenient. 

Conclusion: Overall, the drive-through medical system was perceived as more convenient than the ED and was viewed as a positive experience. While representing a dramatic change in the delivery model of medical care, if such systems can provide comparable levels of care, they may be a viable option for sustained and surge healthcare delivery.

A Global Survey of Emergency Department Responses to the COVID-19 Pandemic

Introduction: Emergency departments (ED) globally are addressing the coronavirus disease 2019 (COVID-19) pandemic with varying degrees of success. We leveraged the 17-country, Emergency Medicine Education & Research by Global Experts (EMERGE) network and non-EMERGE ED contacts to understand ED emergency preparedness and practices globally when combating the COVID-19 pandemic.

Methods: We electronically surveyed EMERGE and non-EMERGE EDs from April 3–June 1, 2020 on ED capacity, pandemic preparedness plans, triage methods, staffing, supplies, and communication practices. The survey was available in English, Mandarin Chinese, and Spanish to optimize participation. We analyzed survey responses using descriptive statistics.

Results: 74/129 (57%) EDs from 28 countries in all six World Health Organization global regions responded. Most EDs were in Asia (49%), followed by North America (28%), and Europe (14%). Nearly all EDs (97%) developed and implemented protocols for screening, testing, and treating patients with suspected COVID-19 infections. Sixty percent responded that provider staffing/back-up plans were ineffective. Many sites (47/74, 64%) reported staff missing work due to possible illness with the highest provider proportion of COVID-19 exposures and infections among nurses.

Conclusion: Despite having disaster plans in place, ED pandemic preparedness and response continue to be a challenge. Global emergency research networks are vital for generating and disseminating large-scale event data, which is particularly important during a pandemic.

  • 4 supplemental ZIPs

Efficacy of Various Facial Protective Equipment for Infection Control in a Healthcare Setting

Introduction: The coronavirus 2019 (COVID-19) pandemic has reinforced the importance of facial protection against droplet transmission of diseases. Healthcare workers wear personal protection equipment (PPE), including face shields and masks. Plastic face shields may have advantages over regular medical masks. Although many designs of face shields exist, there is a paucity of evidence regarding the efficacy of shield designs against droplet transmissions. There is even less published evidence comparing various face shields. Due to the urgency of the pandemic and the health and safety of healthcare workers, we aimed to study the efficacy of various face shields against droplet transmission.

Methods: We simulated droplet transmission via coughing using a heavy-duty chemical spray bottle filled with fluorescein. A standard-adult sized mannequin head was used. The mannequin head wore various face shields and was positioned to face the spray bottle at either a 0°, 45°, or 90° angle. The spray bottle was positioned at and sprayed from 30 centimeters (cm), 60 cm, or 90 cm away from the head. These steps were repeated for all face shields used. Control was a mannequin that wore no PPE. A basic mask was also tested. We collected data for particle count, total area of particle distribution, average particle size, and percentage area covered by particles. We analyzed percent covered by particles using a repeated measures mixed-model regression with Tukey-Kramer pairwise comparison.

Results: We used least square means to estimate the percentage area covered by particles. Wearing PPE regardless of the design reduced particle transmission to the mannequin compared to the control. The LCG mask had the lowest square means of 0.06 of all face-shield designs analyzed. Tukey-Kramer pairwise comparison showed that all PPEs had a decrease in particle contamination compared to the control. LCG shield was found to have the least contamination compared to all other masks (P < 0.05).

Conclusion: Results suggest the importance of wearing a protective covering against droplet transmission. The LCG shield was found to decrease facial contamination by droplets the most of any tested protective equipment.


  • 1 supplemental ZIP

Mortality Variations of COVID-19 from Different Hospital Settings During Different Pandemic Phases: A Multicenter Retrospective Study

Introduction: Diverse coronavirus disease 2019 (COVID-19) mortalities have been reported but focused on identifying susceptible patients at risk of more severe disease or death. This study aims to investigate the mortality variations of COVID-19 from different hospital settings during different pandemic phases.

Methods: We retrospectively included adult (≥18 years) patients who visited emergency departments (ED) of five hospitals in the state of Texas and who were diagnosed with COVID-19 between March–November 2020. The included hospitals were dichotomized into urban and suburban based on their geographic location. The primary outcome was mortality that occurred either during hospital admission or within 30 days after the index ED visit. We used multivariable logistic regression to investigate the associations between independent variables and outcome. Generalized additive models were employed to explore the mortality variation during different pandemic phases.

Results: A total of 1,788 adult patients who tested positive for COVID-19 were included in the study. The median patient age was 54.6 years, and 897 (50%) patients were male. Urban hospitals saw approximately 59.5% of the total patients. A total of 197 patients died after the index ED visit. The analysis indicated visits to the urban hospitals (odds ratio [OR] 2.14, 95% confidence interval [CI], 1.41, 3.23), from March to April (OR 2.04, 95% CI, 1.08, 3.86), and from August to November (OR 2.15, 95% CI, 1.37, 3.38) were positively associated with mortality.

Conclusion: Visits to the urban hospitals were associated with a higher risk of mortality in patients with COVID-19 when compared to visits to the suburban hospitals. The mortality risk rebounded and showed significant difference between urban and suburban hospitals since August 2020. Optimal allocation of medical resources may be necessary to bridge this gap in the foreseeable future.


Impact of COVID-19 and Shelter in Place on Volume and Type of Traumatic Injuries

Introduction: Very little is known about the effects of the novel coronavirus (COVID-19) pandemic and its associated social distancing practices on trauma presentations to the emergency department (ED). This study aims to assess the impact of a city-wide stay at home order on the volume, type, and outcomes of traumatic injuries at urban EDs.

Methods: The study was a retrospective chart review of all patients who presented to the ED of an urban Level I Trauma Center and its urban community affiliate in the time period during the 30 days before the institution of city-wide shelter-in-place (preSIP) order and 60 days after the shelter-in-place (SIP) order and the date-matched time periods in the preceding year. Volume and mechanism of traumatic injuries were compared using paired T-tests.  

Results: There was a significant decrease in overall ED volume. The volume of certain blunt trauma presentations (motor vehicle collisions) during the first 60 days of SIP compared to the same period from the year prior also significantly decreased. Importantly, the volume of penetrating injuries, including gunshot wounds and stab wounds, did not differ for the preSIP and SIP periods when compared to the prior year. The mortality of traumatic injuries was also unchanged during the SIP comparison period.

Conclusion: While there were significant decreases in visits to the ED and overall trauma volume, penetrating trauma, including gun violence, and other severe traumatic injuries remain a public health crisis that affects urban communities despite social distancing recommendations enacted during the COVID-19 pandemic.

Behavioral Health

Positive Toxicology Results Are Not Associated with Emergency Physician’s Opioid Prescribing Behavior

Introduction: Given the general lack of literature on opioid and naloxone prescribing guidelines for patients with substance use disorder, we aimed to explore how a physician’s behavior and prescribing habits are altered by knowledge of the patient’s concomitant use of psychotropic compounds as evident on urine and serum toxicology screens.

Methods: We conducted a retrospective chart review study at a tertiary, academic, Level I trauma center between November 2017–October 2018 that included 358 patients who were discharged from the emergency department (ED) with a diagnosis of fracture, dislocation, or amputation and received an opioid prescription upon discharge. We extracted urine and serum toxicology results, number and amount of prescription opioids upon discharge, and the presence of a naloxone script.

Results: The study population was divided into five subgroups that included the following: negative urine and serum toxicology screen; depressants; stimulants; mixed; and no toxicology screens. When comparing the 103 patients in which toxicology screens were obtained to the 255 patients without toxicology screens, we found no statistically significant differences in the total prescribed morphine milligram equivalent (75.0 and 75.0, respectively) or in the number of pills prescribed (15.0 and 13.5, respectively). Notably, none of the 103 patients who had toxicology screens were prescribed naloxone upon discharge.

Conclusion: Our study found no association between positive urine toxicology results for psychotropically active substances and the rates of opioid prescribing within a single-center, academic ED. Notably, none of the 103 patients who had toxicology screens were prescribed naloxone upon discharge. More research on the associations between illicit drug use, opioids, and naloxone prescriptions is necessary to help establish guidelines for high-risk patients.

  • 1 supplemental ZIP

Emergency Department Visits by Patients with Substance Use Disorder in the United States

Introduction: We aimed to characterize emergency department (ED) utilization and clinical characteristics of patients with substance use disorder (SUD) seeking emergency care for all reasons.

Methods: Using 2016–2017 ED data from the National Hospital Ambulatory Medical Care Survey, we investigated demographics, ED resource utilization, and clinical characteristics of patients with SUD vs those without SUD. 

Results: Of all adult ED visits (N = 27,609) in the US in 2016–2017, 11.1% of patients had SUD. Among ED patients with SUD, they were mostly non-Hispanic White (62.5%) and were more likely to be male (adjusted odds ratio [aOR] 1.80 confidence interval [CI], 1.66-1.95). Emergency department patients with SUD were also more likely to return to the ED within 72 hours (aOR 1.32, CI, 1.09-1.61) and more likely to be admitted to the hospital (aOR 1.28, CI, 1.14-1.43) and intensive care unit (aOR 1.40, CI, 1.05-1.85).

Conclusion: Patients with SUD have specific demographic, socioeconomic, and clinical characteristics associated with their ED visits. These findings highlight the importance of recognizing co-existing SUD as risk factors for increasing morbidity in acutely ill and injured patients, and the potential role of the ED as a site for interventions aimed at reducing harm from SUD.

  • 1 supplemental ZIP

Mobile Crisis Outreach and Emergency Department Utilization: A Propensity Score-matched Analysis

Introduction: Mental health and substance use disorder (MHSUD) patients in the emergency department (ED) have been facing increasing lengths of stay due to a shortage of inpatient beds. Previous research indicates mobile crisis outreach (MCO) reduces long ED stays for MHSUD patients. Our objective was to assess the impact of MCO contact on future ED utilization.

Methods: We conducted a retrospective chart review of patients presenting to a large Midwest university ED with an MHSUD chief complaint from 2015–2018. We defined the exposure as those who had MCO contact and any MHSUD-related ED visit within 30 days of MCO contact. The MCO patients were 2:1 propensity score–matched by demographic data and comorbidities matched to patients with no MCO contact. Outcomes were all-cause and psychiatric-specific reasons for return to the ED within one year of the index ED visit. We report descriptive statistics and odds ratios (OR) to describe the difference between the two groups, and hazard ratios (HR) to estimate the risk of return ED visit. 

Results: The final sample included 106 MCO and 196 non-MCO patients. The MCO patients were more likely to be homeless (OR 14.8; 95% confidence interval [CI],1.87, 117), less likely to have adequate family or social support (OR 0.51; 95% CI, 0.31, 0.84), and less likely to have a hospital bed requested for them in the index visit by ED providers (OR 0.50; 95% CI, 0.29, 0.88). For those who returned to the ED, the median time for all-cause return to the ED was 28 days (interquartile range [IQR]: 6–93 days) for the MCO patients and 88 days (IQR: 20–164 days) for non-MCO patients. The risk of all-cause return to the ED was greater among MCO patients (67%) compared to non-MCO patients (49%) (adjusted HR: 1.66; 95% CI, 1.22, 2.27). 

Conclusion: The MCO patients had less family and social support; however, they were less likely to require hospitalization for each visit, likely due to MCO involvement. Patients with MCO contact presented to the ED more frequently than non-MCO patients, which implies a strong linkage between the ED and MCO in our community. An effective referral to community service from the ED and MCO and collaboration could be the next step to improve healthcare utilization.

  • 1 supplemental ZIP


National Survey of Point-of-Care Ultrasound Scholarly Tracks in Emergency Medicine Residency Programs

Introduction: Residency scholarly tracks are educational programs, designed to help trainees develop an area of expertise. Although the breadth of residency point-of-care ultrasound (POCUS) education has developed considerably in recent years, there is no literature to date describing scholarly tracks specifically in POCUS. In this study we sought to determine the prevalence, characteristics, and outcomes of POCUS scholarly tracks in emergency medicine (EM).

Methods: This was a cross-sectional survey of EM residency programs accredited by the Accreditation Council for Graduate Medical Education. Surveys were distributed between March-August 2020 using a listserv followed by targeted emails to residency and ultrasound leadership. We summarized data using descriptive statistics, and performed logistic regression to identify factors associated with a POCUS scholarly track.

Results: Of 267 residency programs 199 (74.5%) completed the survey. Fifty-seven (28.6%) had a POCUS scholarly track as of the 2019-2020 academic year. Scholarly tracks in POCUS were more common in university-based/academic sites and larger residency programs. Of the 57 programs with POCUS scholarly tracks, 48 (84.2%) required residents to present at least one POCUS lecture, 45 (78.9%) required residents to serve as instructor at a hands-on workshop, and 42 (73.7%) required residents to participate in quality assurance of departmental POCUS scans. Only 28 (49.1%) tracks had a structured curriculum, and 26 (45.6%) required POCUS research. In total, 300 EM residents completed a POCUS scholarly track over the past three academic years, with a median of 4 (2-9) per program. Seventy-five (25.0%) proceeded to a clinical ultrasound fellowship after residency graduation, with a median of 1 (interquartile range 0-2) per program. A total of 139 POCUS-specific abstracts (median 2 [0-3]) and 80 peer-reviewed manuscripts (median 1 [0-2]) were published by scholarly track residents over the past three years.

Conclusion: This survey study describes the current prevalence, characteristics, and outcomes of POCUS scholarly tracks across EM residency programs. The results may inform the decisions of residency programs to create these tracks.

  • 2 supplemental ZIPs

Does the Medical Student Performance Evaluation Change the Decision to Invite Residency Applicants?

Introduction: Although emergency medicine (EM) residency program directors (PD) have multiple sources to evaluate each applicant, some programs await the release of the medical student performance evaluation (MSPE) to extend interview offers. While prior studies have demonstrated that MSPE content is variable and selectively positive, no prior work has evaluated the impact of the MSPE on the likelihood to invite (LTI) applicants for a residency interview. This study aimed to evaluate how information in the MSPE impacted LTI, with the hypothesis that changes in LTI would be relatively rare based on MSPE review alone. 

Methods: We conducted a prospective, observational study analyzing applications to three EM residency programs during the 2019-2020 match cycle. Reviewers assessed applications and rated the LTI on a five-point Likert scale where LTI was defined as follows: 1 = definitely no; 2 = probably no; 3 = unsure; 4 = probably yes; and 5 = definitely yes. The LTI was recorded before and after MSPE review. A change in LTI was considered meaningful when it changed the overall trajectory of the applicant’s likelihood to receive an invitation to interview. 

Results: We reviewed a total of 877 applications with the LTI changing ≥1 point on the Likert scale 160 (18.2%) times. The LTI was meaningfully impacted in a minority of applications – 48 total            (5.5 %, p< 0.01) – with only 1 (0.11%) application changing from 1 or 2 (definitely/probably no) to 4 or 5 (probably/definitely yes) and 34 (3.8%) changing from 3 (unsure) to 4 or 5 (probably/definitely yes). Thirteen (1.5%) applications changed from 4 or 5 (probably/definitely yes) to 3 (unsure or probably/definitely no).

Conclusion: Review of the MSPE resulted in a meaningful change in LTI in only 5.5% of applications. Given the time required for program leadership to review all parts of the variably formatted MSPEs, this finding supports a more efficient application review, where the PD’s focus is on succinct and objective aspects of the application, such as the Standardized Letter of Evaluation.

  • 2 supplemental ZIPs

Radiology Education Among Emergency Medicine Residencies: A National Needs Assessment

Introduction: Radiology training is an important component of emergency medicine (EM) education, but its delivery has been variable. Program directors have reported a lack of radiology skills in incoming interns. A needs assessment is a crucial first step toward improving radiology education among EM residencies. Our objective was to explore the current state of radiology education in EM residency programs.

Methods: This was a cross-sectional survey study of all Accreditation Council for Graduate Medical Education-accredited EM programs in the United States. Program leadership completed an online survey consisting of multiple choice, Likert scale, and free-response items. We calculated and reported descriptive statistics.

Results: Of eligible EM programs, 142/252 (56%) completed the survey including 105 postgraduate year (PGY) 1-3 and 36 PGY 1-4 programs. One respondent opted out of answering demographic questions. 23/141 (16%) were from the Western region, 29/141 (21%) were from the North Central region, 14/141 (10%) were from the South-Central region, 28/141 (20%) were from the Southeast region, and 47/141 (33%) were from the Northeast region. A total of 88/142 (62%) of responding programs did not have formal radiology instruction. Of the education that is provided, 127/142 (89%) provide it via didactics/lectures and 115/142 (81%) rely on instruction during clinical shifts. Only 51/142 (36%) provide asynchronous opportunities, and 23/142 (16%) have a dedicated radiology rotation. The majority of respondents reported spending 0-2 hours per month on radiology instruction (108/142; 76%); 95/141 (67%) reported that EM faculty “often” or “always” provide radiology instruction; 134/142 (95%), felt that it was “extremely” or “very important” for ED providers to be able to independently interpret radiograph results; and 129/142 (90.84%) either “sometimes” or “always” rely on their independent radiograph interpretations to make clinical decisions. The radiology studies identified as most important to be able to independently interpret were radiographs obtained for lines/tubes, chest radiographs, and radiographs obtained for musculoskeletal-related complaints.

Conclusion: A minority of EM residency programs have formal instruction in radiology despite the majority of responding program leadership believing that these are important skills. The most important curricular areas were identified. These results may inform the development of formal radiology curricula in EM graduate medical education.

  • 1 supplemental ZIP

Health Outcomes

Cancer-related Emergency Department Visits: Comparing Characteristics and Outcomes

Introduction: There is increasing appreciation of the challenges of providing safe and appropriate care to cancer patients in the emergency department (ED). Our goal here was to assess which patient characteristics are associated with more frequent ED revisits.

Methods: This was a retrospective cohort study of all ED visits in California during the 2016 calendar year using data from the California Office of Statewide Health Planning and Development. We defined revisits as a return visit to an ED within seven days of the index visit. For both index and return visits, we assessed various patient characteristics, including age, cancer type, medical comorbidities, and ED disposition.

Results: Among 12.9 million ED visits, we identified 73,465 adult cancer patients comprising 103,523 visits that met our inclusion criteria. Cancer patients had a 7-day revisit rate of 17.9% vs 13.2% for non-cancer patients. Cancer patients had a higher rate of admission upon 7-day revisit (36.7% vs 15.6%). Patients with cancers of the small intestine, stomach, and pancreas had the highest rate of 7-day revisits (22-24%). Cancer patients younger than 65 had a higher 7-day revisit rate than the elderly (20.0% vs 16.2%).

Conclusion: In a review of all cancer-related ED visits in the state of California, we found a variety of characteristics associated with a higher rate of 7-day ED revisits. Our goal in this study was to inform future research to identify interventions on the index visit that may improve patient outcomes.

  • 2 supplemental ZIPs

Inpatient Outcomes Following a Return Visit to the Emergency Department: A Nationwide Cohort Study

Introduction: Emergency department (ED) revisits are traditionally used to measure potential lapses in emergency care. However, recent studies on in-hospital outcomes following ED revisits have begun to challenge this notion. We aimed to examine inpatient outcomes and resource use among patients who were hospitalized following a return visit to the ED using a national database.

Methods: This was a retrospective cohort study using the National Health Insurance Research Database in Taiwan. One-third of ED visits from 2012–2013 were randomly selected and their subsequent hospitalizations included. We analyzed the inpatient outcomes (mortality and intensive care unit [ICU] admission) and resource use (length of stay [LOS] and costs). Comparisons were made between patients who were hospitalized after a return visit to the ED and those who were hospitalized during the index ED visit. 

Results: Of the 3,019,416 index ED visits, 477,326 patients (16%) were directly admitted to the hospital. Among the 2,504,972 patients who were discharged during the index ED visit, 229,059 (9.1%) returned to the ED within three days. Of them, 37,118 (16%) were hospitalized. In multivariable analyses, the inpatient mortality rates and hospital LOS were similar between the two groups. Compared with the direct-admission group, the return-admission group had a lower ICU admission rate (adjusted odds ratio, 0.78; 95% confidence interval [CI], 0.72-0.84), and lower costs (adjusted difference, -5,198 New Taiwan dollars, 95% CI, -6,224 to -4,172).  

Conclusion: Patients who were hospitalized after a return visit to the ED had a lower ICU admission rate and lower costs, compared to those who were directly admitted. Our findings suggest that ED revisits do not necessarily translate to poor initial care and that subsequent inpatient outcomes should also be considered for better assessment.

Evaluation of the Initial General Ward Early Warning Score and ICU Admission, Hospital Length of Stay and Mortality

Introduction: Despite widespread implementation of the Early Warning Score (EWS) in hospitals, its effect on patient outcomes remains mostly unknown. We aimed to evaluate associations between the initial EWS and in-hospital mortality, intensive care unit (ICU) admission, and hospital length of stay (LOS). 

Methods: We performed a retrospective cohort study of adult patients admitted to a general hospital ward between July 1, 2014–December 31, 2017. Data were obtained from electronic health records (EHR). The primary outcome was in-hospital mortality. Secondary outcomes were ICU admission and hospital LOS. We categorized patients into three risk groups (low, medium or high risk of clinical deterioration) based on EWS. Descriptive analyses were used.

Results: After applying inclusion and exclusion criteria, we included 53,180 patients for analysis. We found that the initial (low- vs high-risk) EWS was associated with an increased in-hospital mortality (1.5% vs 25.3%, P <0.001), an increased ICU admission rate (3.1% vs 17.6%, P <0.001), and an extended hospital LOS (4.0 days vs 8.0 days, P <0.001).

Conclusion: Our findings suggest that an initial high-risk EWS in patients admitted to a general hospital ward was associated with an increased risk of in-hospital mortality, ICU admission, and prolonged hospital LOS. Close monitoring and precise documentation of the EWS in the EHR may facilitate predicting poor outcomes in individual hospitalized patients and help to identify patients for whom timely and adequate management may improve outcomes.


Toxicologic Exposures in California Emergency Departments in 2011 and Its Risk Factors

Introduction: Toxicologic exposures (TE) are a major preventable public health issue, with most cases due to unintentional causes. Although these cases are well documented and reported via the National Poison Data System, there is little information regarding toxicologic exposure cases in the emergency department (ED). The aim of this study was to identify demographic groups at risk for potential poisoning.

Methods: This was a cross-sectional study. We used data from the California State Emergency Department Database (SEDD) 2011 for statistical analysis.

Results: The study included 10,124,598 ED visits in California in 2011. The prevalence of TE was 383.4 (379.6-387.3) per 100,000 visits. Toxicologic exposures were most common among patients aged <10 years (555.4, 95% confidence interval [CI], 544.5-566.5 per 100,000 visits). Overall, TE was more common among males. White patients showed the highest prevalence of TE compared to other racial groups (P <0.001). Subpopulation analysis showed Native American female patients ages 10-19 had a noticeably higher prevalence of TE (1,464.4, 95% CI, 802.9-2444.9 per 100,000). The prevalence of TE was higher in households of higher median income (P <0.001). Prevalence of TE among those with a history of substance use was also elevated. 

Conclusion: Toxicologic exposure cases in the ED are elevated in particular age and race/ethnicity groups, as well as among those with a diagnosis of substance use disorder. The strength of association between these factors and TE in the general population may be different because we examined ED visits only. Further preventive and education strategies are necessary and should target the demographic groups identified in this epidemiological study.

Cannabis in Homes with Children: A Survey on Use, Storage, and Attitudes

Introduction: The recent legalization of cannabis in California has the potential to affect cannabis prevalence in households with children. This eventuality, combined with suboptimal cannabis storage practices, could lead to adverse effects such as unintentional pediatric ingestion, which occurred in Colorado after legalization. Our objective was to assess prevalence and storage practices of cannabis in households with children, and attitudes on use and storage education in a state that has legalized cannabis.

Methods: We administered electronic surveys to 401 adults in a pediatric emergency department in California. Participants were excluded if they were not English- or Spanish-speaking or did not live in a household with children <18 years old. They answered questions regarding cannabis use, storage, and attitudes on cannabis storage education. We used convenience sampling and analyzed data using descriptive statistics. 

Results: Research assistants approached 558 participants of whom 401 completed the survey. Three participants did not respond regarding past or current cannabis use, and 14.5% (58/401) reported cannabis use in their home in the prior six months. Both users and non-users rated safe storage of high importance in homes with children. Only 44.8% of home users (26/58) reported that their cannabis was both locked and hidden. Among home users, the most common source of storage advice was friends and family (21/58, 36.2%), and 45% of home users (26/58) received no storage information whatsoever. Most cannabis users (53/67, 79.1%) and non-users (241/330, 73%) reported that they would feel comfortable receiving cannabis education from their primary care provider.  

Conclusion: Cannabis is used and stored in homes with children; however, safe storage is not clearly defined in California, and storage education is lacking. Healthcare providers in primary care and the emergency department may play an important role in educating the public about cannabis use and safe storage.

Emergency Medicine Workforce

Comparing Physician Assistant and Nurse Practitioner Practice in U.S. Emergency Departments, 2010–2017

Introduction: We sought to compare physician assistant (PA) and nurse practitioner (NP) practice in United States emergency departments (ED) based on ED visits as reported by the National Hospital Ambulatory Medical Care Survey (NHAMCS). 

Methods: We performed a retrospective, secondary analysis of the 2010 to 2017 NHAMCS with analysis of ED visits, patient demographics, and hospital characteristics. 

Results: Between 2010 to 2017, 21.0% (95% confidence interval, [CI] +/-3.1%) of ED visits were seen by either a PA/NP (with and without physician involvement) and 8.6% (+/-2.9%) were seen by PA/NP alone. We identified an increase for NP visits between 2014–2016 and found that PA/NP visits share many of the same characteristics. 

Conclusion: While emergency medicine has predominately been a specialty for PAs, the number of ED visits with NPs has been increasing over the past several years. While there are some differences, PAs/NPs share many similar practice characteristics in the ED.

Clinical Practice

A Clinical Prediction Tool for MRI in Emergency Department Patients with Spinal Infection

Introduction: Patients with pyogenic spinal Infection (PSI) are often not diagnosed at their initial presentation, and diagnostic delay is associated with increased morbidity and medical-legal risk. We derived a decision tool to estimate the risk of spinal infection and inform magnetic resonance imaging (MRI) decisions.

Methods: We conducted a two-part prospective observational cohort study that collected variables from spine pain patients over a six-year derivation phase. We fit a multivariable regression model with logistic coefficients rounded to the nearest integer and used them for variable weighting in the final risk score. This score, SIRCH (spine infection risk calculation heuristic), uses four clinical variables to predict PSI. We calculated the statistical performance, MRI utilization, and model fit in the derivation phase. In the second phase we used the same protocol but enrolled only confirmed cases of spinal infection to assess the sensitivity of our prediction tool.

Results: In the derivation phase, we evaluated 134 non-PSI and 40 PSI patients; median age in years was 55.5 (interquartile range [IQR] 38-70 and 51.5 (42-59), respectively. We identified four predictors for our risk score: historical risk factors; fever; progressive neurological deficit; and C-reactive protein (CRP) ≥ 50 milligrams per liter (mg/L). At a threshold SIRCH score of ≥ 3, the predictive model’s sensitivity, specificity, and positive predictive value were, respectively, as follows: 100% (95% confidence interval [CI], 100-100%); 56% (95% CI, 48-64%), and 40% (95% CI, 36-46%). The area under the receiver operator curve was 0.877 (95% CI, 0.829-0.925). The SIRCH score at a threshold of ≥ 3 would prompt significantly fewer MRIs compared to using an elevated CRP (only 99/174 MRIs compared to 144/174 MRIs, P <0.001). In the second phase (49 patient disease-only cohort), the sensitivities of the SIRCH score and CRP use (laboratory standard cut-off 3.5 mg/L) were 92% (95% CI, 84-98%), and 98% (95% CI, 94-100%), respectively.

Conclusion: The SIRCH score provides a sensitive estimate of spinal infection risk and prompts fewer MRIs than elevated CRP (cut-off 3.5 mg/L) or clinician suspicion.

  • 1 supplemental ZIP


A Multivariable Model of Parent Satisfaction, Pain, and Opioid Administration in a Pediatric Emergency Department

Introduction: Children and adolescents are not impervious to the unprecedented epidemic of opioid misuse in the United States. In 2016 more than 88,000 adolescents between the ages of 12–17 reported misusing opioid medication, and evidence suggests that there has been a rise in opioid-related mortality for pediatric patients. A major source of prescribed opioids for the treatment of pain is the emergency department (ED). The current study sought to assess the complex relationship between opioid administration, pain severity, and parent satisfaction with children’s care in a pediatric ED.

Methods: We examined data from a tertiary pediatric care facility. A health survey questionnaire was administered after ED discharge to capture the outcome of parental likelihood of providing a positive facility rating. We abstracted patient demographic, clinical, and top diagnostic information using electronic health records. Data were merged and multivariable models were constructed. 

Results: We collected data from 15,895 pediatric patients between the ages of 0–17 years (mean = 6.69; standard deviation = 5.19) and their parents. Approximately 786 (4.94%) patients were administered an opioid; 8212 (51.70%) were administered a non-opioid analgesic; and 3966 (24.95%) expressed clinically significant pain (pain score >/= 4). Results of a multivariable regression analysis from these pediatric patients revealed a three-way interaction of age, pain severity, and opioid administration (odds ratio 1.022, 95% confidence interval, 1.006, 1.038, P = 0.007). Our findings suggest that opioid administration negatively impacted parent satisfaction of older adolescent patients in milder pain who were administered an opioid analgesic, but positively influenced the satisfaction scores of parents of younger children who were administered opioids. When pain levels were severe, the relationship between age and patient experience was not statistically significant.

Conclusion: This investigation highlights the complexity of the relationship between opioid administration, pain severity, and satisfaction, and suggests that the impact of opioid administration on parent satisfaction is a function of the age of the child.

Population Health Research Design

Enroller Experience and Parental Familiarity of Disease Influence Participation in a Pediatric Trial

Introduction: Acquiring parental consent is critical to pediatric clinical research, especially in interventional trials. In this study we investigated demographic, clinical, and environmental factors associated with likelihood of parental permission for enrollment in a study of therapies for diabetic ketoacidosis (DKA) in children.

Methods: We analyzed data from patients and parents who were approached for enrollment in the Pediatric Emergency Care Applied Research Network (PECARN) Fluid Therapies Under Investigation in DKA (FLUID) trial at one major participating center. We determined the influence of various factors on patient enrollment, including gender, age, distance from home to hospital, insurance status, known vs new onset of diabetes, glycemic control (hemoglobin A1c), DKA severity, gender of the enroller, experience of the enroller, and time of enrollment. Patients whose parents consented to participate were compared to those who declined participation using bivariable and multivariable analyses controlling for the enroller.

Results: A total of 250 patient/parent dyads were approached; 177 (71%) agreed to participate, and 73 (29%) declined. Parents of patients with previous episodes of DKA agreed to enroll more frequently than those with a first DKA episode (94.3% for patients with 1-2 previous DKA episodes, 92.3% for > 2 previous episodes, vs 64.9% for new onset diabetes and 63.2% previously diagnosed but no previous DKA). Participation was also more likely with more experienced enrollers (odds ratio [95% confidence interval] of participation for an enroller with more than two years’ experience vs less than two years: 2.46 [1.53, 3.97]). After adjusting for demographic and clinical factors, significant associations between participation and both DKA history and enroller experience remained. Patient age, gender, distance of home from hospital, glycemic control, insurance status, and measures of DKA severity were not associated with likelihood of participation.

Conclusion: Familiarity with the disease process (previously diagnosed diabetes and previous experience with DKA) and experience of the enroller favorably influenced the likelihood of parental permission for enrollment in a study of DKA in children.

Emergency Medical Services

Outcomes Associated with Lower Doses of Ketamine by Emergency Medical Services for Profound Agitation

Introduction: Ketamine is commonly used to treat profound agitation in the prehospital setting. Early in ketamine’s prehospital use, intubation after arrival in the emergency department (ED) was frequent. We sought to measure the frequency of ED intubation at a Midwest academic medical center after prehospital ketamine use for profound agitation, hypothesizing that intubation has become less frequent as prehospital ketamine has become more common and prehospital dosing has improved.

Methods: We conducted a retrospective cohort study of adult patients receiving ketamine in the prehospital setting for profound agitation and transported to a midwestern, 60,000-visit, Level 1 trauma center between January 1, 2017–- March 1, 2021. We report descriptive analyses of patient-level prehospital clinical data and ED outcomes. The primary outcome was proportion of patients intubated in the ED. 

Results: A total of 78 patients received ketamine in the prehospital setting (69% male, mean age 36 years). Of the 42 (54%) admitted patients, 15 (36% of admissions) were admissions to the intensive care unit. Overall, 12% (95% confidence interval [CI]), 4.5-18.6%)] of patients were intubated, and indications included agitation (n = 4), airway protection not otherwise specified (n = 4), and respiratory failure (n = 1). 

Conclusion: Endotracheal intubation in the ED after prehospital ketamine use for profound agitation in our study sample was found to be less than previously reported.


Cervical Spine Injuries in Older Patients with Falls Found on Magnetic Resonance Imaging After Computed Tomography

Introduction: In this study we aimed to determine the rate of traumatic abnormalities on cervical spine magnetic resonance imaging (MRI) after a normal cervical spine computed tomography (CT) in older patients with ground-level falls. We hypothesized that MRI is low yield following a normal physical examination and normal CT after a ground-level fall. 

Methods: This was a retrospective cohort study of patients 65 years and older evaluated with a cervical spine MRI following a ground-level fall. Inclusion criteria included age 65 years and older, ground-level fall, normal cervical spine CT followed by a cervical spine MRI. We abstracted data following accepted methodologic guidelines. Patients with any focal neurological finding were considered to have an abnormal neurological examination. Imaging studies were considered to be abnormal if there was a report of an acute traumatic injury. The primary outcome was a traumatic abnormality identified on MRI. We described data with simple descriptive statistics. 

Results: Eighty-seven patients with a median age of 74 (interquartile range [IQR] 69, 83]) years had an MRI following a normal cervical spine CT. Median emergency department length of stay was 8.2 hours (IQR 5.3, 13.5). Sixty-four (73.6%) patients had a normal neurological examination on arrival; eight of these patients (12.5% (95% confidenced interval [CI], 5.6-23.2%) had an abnormal cervical spine MRI. Twenty-three patients (26.4%) had an abnormal neurological examination on arrival; two of these patients (8.7%, 95% CI, 1.1-28%) had an abnormal cervical spine MRI. Overall, 10 patients (11.5%) had an abnormal cervical spine MRI. One patient underwent operative intervention due to an unstable injury. Of the remaining nine patients with acute findings on cervical spine MRI, there were no other unstable injuries; two patients were managed with cervical orthosis, and seven patients had no additional management. 

Conclusion: In this study of older patients with ground-level falls and normal, atraumatic, cervical spine CT, a small portion had traumatic abnormalities on MRI, with few requiring further intervention. Further study is required to identify criteria to determine when MRI should be performed in older patients after a ground-level fall.


Health Policy Perspectives

Balancing Efficiency and Access: Discouraging Emergency Department Boarding in a Global Budget System

Reducing cost without sacrificing quality of patient care is an important yet challenging goal for healthcare professionals and policymakers alike. This challenge is at the forefront in the United States, where per capita healthcare costs are much higher than in similar countries around the world. The state of Maryland is unique in the hospital financing landscape due to its “capitation” payment system (also known as “global budget”), in which revenue for hospital-based services is set at the beginning of the year. Although Maryland’s system has yielded many benefits, including reduced Medicare spending, it also has had unintentional adverse consequences. These consequences, such as increased emergency department boarding and ambulance diversion, constrain Maryland hospitals’ ability to fulfill their role as emergency care providers and act as a safety net for vulnerable patient populations. In this article, we suggest policy remedies to mitigate the unintended consequences of Maryland’s model that should also prove instructive for a variety of emerging alternative payment mechanisms.

Critical Care

The Use of Dexmedetomidine in the Emergency Department: A Cohort Study

Introduction: Management of sedation, analgesia, and anxiolysis are cornerstone therapies in the emergency department (ED). Dexmedetomidine (DEX), a central alpha-2 agonist, is increasingly being used, and intensive care unit (ICU) data demonstrate improved outcomes in patients with respiratory failure. However, there is a lack of ED-based data. We therefore sought to: 1) characterize ED DEX use; 2) describe the incidence of adverse events; and 3) explore factors associated with adverse events among patients receiving DEX in the ED.

Methods: This was a single-center, retrospective, cohort study of consecutive ED patients administered DEX (January 1, 2017–July 1, 2019) at an academic, tertiary care ED with an annual census of ~90,000 patient visits. All included patients (n= 103) were analyzed for characterization of DEX use in the ED. The primary outcome was a composite of adverse events, bradycardia and hypotension. Secondary clinical outcomes included ventilator-, ICU-, and hospital-free days, and hospital mortality. To examine for variables associated with adverse events, we used a multivariable logistic regression model.

Results: We report on 103 patients. Dexmedetomidine was most commonly given for acute respiratory failure, including sedation for mechanical ventilation (28.9%) and facilitation of non-invasive ventilation (17.4%). Fifty-four (52.4%) patients experienced the composite adverse event, with hypotension occurring in 41 patients (39.8%) and bradycardia occurring in 18 patients (17.5%). Dexmedetomidine was stopped secondary to an adverse event in eight patients (7.8%). Duration of DEX use in the ED was associated with an increase adverse event risk (adjusted odds ratio, 1.004; 95% confidence interval, 1.001, 1.008).

Conclusion: Dexmedetomidine is most commonly administered in the ED for patients with acute respiratory failure. Adverse events are relatively common, yet DEX is discontinued comparatively infrequently due to adverse events. Our results suggest that DEX could be a viable option for analgesia, anxiolysis, and sedation in ED patients.

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